Current Methods of Improving Adherence Do Not Work

Behavior, including adherence behavior, are the keys to improving outcome in a variety of diseases. We must rethink our adherence strategy by using Intelligent Engagement to control the plecosystem of adherence technologies.

First of a Series: Behavior is the Problem

For nearly a half century our nation has watched a rising wave that is now becoming a tsunami; the rise in prediabetes and diabetes. This series of articles will use prediabetes and diabetes as a proof that existing approaches to create a healthy nation do not work and define possible tactical approaches as well as a strategy for a comprehensive solution.

But, do not get caught up with diabetes. Virtually all diseases can benefit from an integrated solution. Our primary problem in healthcare is behavior. Not adherence, not lack of the latest pharmaceutical, not lack of managed care; simply behavior.

If you think about it, most disease has a behavioral component that contributes to the development or worsening of the disease or condition; a behavior that can be modified. A review of the National Health and Nutrition Examination Survey (NHANES) data set over time clearly demonstrates that our health has deteriorated for more than a half century. An analysis of the NHANES data published in JAMA in 2013 concluded that the healthiest generation was composed of those who lived through World War II—the parents of the baby boomers. All other generations following are demonstrating a state of worse health than the war generation. Just as a reminder, longer life span does not indicate better health. The baby boomers are living longer, but only because of advanced, expensive medical intervention. The war generation had fewer people with diabetes, fewer using canes and other measures of health. But, this can be reversed if we dramatically change behavior.

Behavior good and bad, affects virtually all diseases. Some diseases are directly related to bad health; ie smoking and obesity. Other health conditions are made worse by behavior, or probably better said, bad behavior. This omitted or committed behavior prevents the promise of evidence based medical outcome; from arthritis to Alzheimer’s disease, HIV to cardiovascular disease, from fractures in the elderly to diabetes; behavior can make a difference. Managed care companies, employers and other large organizations such as Walgreens have taken notice by creating programs to address this issue.

This move from “healthcare to health” is being embraced in a variety of ways by the explosion of wearables, apps, devices, systems, software applications, and other technology approaches hoping that it may make a meaningful difference. John Mattison, MD, chief medical information officer of Kaiser Permanente coined the word “plecosystem” to describe his vision of the future; an ecosystem composed of technology platforms to handle healthcare.

But it is a stretch of logic to assume that one approach, app, device, drug, technology, or even a “plecosystem” will solve our massive primary issues in healthcare without a fundamental change in our approach to the person facing a disease. Dennis Robbins, healthcare futurist, has used the phrase "person-centric" to describe a healthcare delivery system focused not on patients, who he considers passive and dependent, but on people; people who can then be activated to focus on their health and effectively change health behavior. He feels that anyone who has studied health and disease in the United States cannot ignore the fact that lack of adherence to evidence based guidelines and positive lifestyle change is the foundation for our ill society and the key to changing it.

What is needed is an integrated approach that fits into the natural flow of our busy day; that can tie together a variety of technologies and even plecosystems … to change health behavior. And, we must also take into account behavioral economics. Humans can always be counted on to take the route of least resistance; one that requires the least thinking. We are certainly “creatures of habit.” In addition, any comprehensive solution must take into account both the intrinsic and extrinsic motivational pathways. I envision the use of artificial intelligence and natural language processing to create avatars that then become a key component of the plecosystem to finally lead the change so desperately needed in the US.